CASE REPORT
Killian-Jamieson Diverticulum: The Rarer Cervical
Esophageal Diverticulum
C H Chea, MD, S L Siow, MS, T W Khor, MS, N A Nik Azim, MS
Department of Surgery, Sarawak General Hospital, Jalan Hospital, 93586 Kuching, Sarawak, Malaysia
SUMMARY
Killian-Jamieson (K-J) diverticulum is a rare cervical
oesophageal diverticulum, less commonly encountered
compared with Zenkers diverticulum (ZD). We report a case
of K-J diverticulum in a 52-year-old lady who presented with
sensation of lump in the neck and food stuck in the throat
of 5 years duration. Esophagogram showed a large right-
sided pharyngoesophageal diverticulum which was
confirmed on endoscopy. The patient underwent a
diverticulopexy and recovered without complications. Her
symptoms had improved. In this report, we review the
literature and describe our surgical technique.
KEY WORDS:
Killian-Jamieson diverticulum, Cervical esophageal diverticulum,
Zenkers diverticulum, Pharngoesophageal diverticulum,
Diverticulopexy
INTRODUCTION
Killian-Jamieson (K-J) diverticulum was first described by
Ekberg and Nylander in 19831. It is a rare cervical
oesophageal diverticulum, less commonly encountered
compared with Zenkers diverticulum (ZD), with an incidence
ratio of 1:42. It has also been referred to as a proximal lateral
cervical esophageal diverticula or as a lateral diverticula
from the pharyngoesophageal junction area1. The diagnosis
and differentiation of these two types of cervical oesophageal
diverticula is by radiological studies and endoscopy. K-J
diverticulum originates on the antero-lateral wall of the
cervical oesophagus through a muscular gap (the Killian-
Jamieson space) below the cricopharyngeus and lateral to the
longitudinal muscle of the oesophagus, whereas ZD develops
at the anatomically weak posterior zone (the Killians
dehiscence) just above the cricopharyngeal muscle1-3. We
present a case of symptomatic K-J diverticulum that was
successfully treated with diverticulopexy and describe our
surgical techniques.
CASE REPORT
A 52-year-old woman presented with sensation of lump in her
neck and food stuck in her throat of five years duration. She
gave history of fruit seed trapped in her throat requiring
endoscopic retrieval 6 years ago. Otherwise, she denied
having dysphagia, odynophagia, halitosis, chronic coughing
or gastro-esophageal reflux symptoms. Clinically, she had a
collar scar over the base of right anterior triangle of the neck
This article was accepted: 21 March 2011
Corresponding Author: Sze Li Siow, Consultant Surgeon, Sarawak General Hospital, Surgery, Jalan Hospital, 93586, Kuching, Sarawak, Malaysia
Email: szeli18@yahoo.com
Med J Malaysia Vol 66 No 1 March 2011
which she attributed to incison and drainage of the neck
abscess 41 years ago. Esophagoscopy showed a large
pharyngoesophageal diverticulum 15-16 cm from the incisor.
Esophagogram showed a large right-sided
pharyngoesophageal diverticulum.
She underwent surgery under general anesthesia. A rigid
esophagoscopy was performed by Ear, Nose and Throat
surgeon at the start of the surgery. She was then placed
supine with the head turned slightly to the left. A collar
incision was made at the right anterior neck with skin flaps
elevated to expose the anterior border of the
sternocleidomastoid. A Jolls thyroid retractor was applied to
retract the upper and lower edges of the wound.
Sternocleidomastoid muscle and the underlying carotid
sheath and contents were retracted laterally away from the
midline. Omohyoid muscle was divided. Thyroid gland was
mobilized with the division of the middle thyroid vein. Right
recurrent laryngeal nerve was then identified and preserved.
The inferior thyroid artery was divided to facilitate retraction
of right lobe of the thyroid medially. The diverticulum was
then dissected free until the neck has been visualized and was
freely mobile. Plication of diverticulum using interrupted
prolene 2/0 was done. A small redivac drain was placed at the
retropharyngeal space.
During the last review at 6 months, she was asymptomatic
and scheduled for further assessment later.
DISCUSSION
A K-J diverticulum is an uncommon cervical esophageal
diverticulum compared to the better recognized ZD. Hence,
it is often unrecognized and misdiagnosed as a ZD on
endoscopy. Its pathogenesis is unclear. It is not a true
diverticulum as it does not involve all layers of the intestinal
wall. It has been suggested that its formation is due to
relatively high intra-luminal pressure building against a
weakness in the gastrointestinal tract wall, i.e. the Killian-
Jamieson space1-2 and that discordant swallowing against a
closed upper esophageal sphincter causes build-up in
oropharyngeal pressure leading to a pulsion-type
diverticulum originating from the K-J space.
Cervical esophageal diverticula typically present with
oropharyngeal dysphagia, usually to solids and liquids.
Retention of food material and secretions in the diverticulum
can result in regurgitation after meals, halitosis, chronic
73
Case Report
Fig. 1: Esophagogram in the frontal position showing a right-
sided diverticulum of the pharyngoesophageal junction.
coughing, and even aspiration pneumonia, especially if the
underlying diverticulum is large. Patients may even notice
food on the pillow upon awakening in the morning. These
symptoms are more likely with ZD, which are attributable to
the underlying diverticulum. In contrast, patients with K-J
diverticulum are usually asymptomatic or have symptoms
attributable to abnormal pharyngeal motility due to the
anatomical location of the diverticulum below the
cricopharyngeus which has remained closed during the
imaging study. In 2001, Rubesin and Levine reviewed the
records and pharyngo-esophagogram of 16 patients with K-J
diverticulum and 26 patients with ZD and found that only
19% of patients with K-J diverticulum were symptomatic
(particularly suprasternal dysphagia) compared to 62% of
patients with ZD. In addition, they found that ZD was larger
than K-J diverticulum, with an average maximal dimension of
2.5 and 1.4cm, respectively2.
A barium contrast esophagography is necessary for the
accurate diagnosis of either ZD or K-J diverticulum. The
location of the opening of the diverticulum in relation to the
cricophayngeus muscle is best shown on pharyngography
when passage of the barium bolus outlines the protruding
cricopharyngeal bar2 which represents constriction of the
cricopharyngeal muscle. ZD originates just above the
cricopharyngeal bar and extends posteriorly, whereas K-J
diverticulum originates below the cricopharyngeal bar and
extends laterally.
Only patients who are symptomatic or who have large
diverticula should be offered treatment. The treatment
options are either surgical or endoscopic. In recent times, the
traditional open surgical approach is being challenged by
endoscopic technique such as endoscopic diverticulotomy3,4.
The aim of performing the diverticulotomy is to create a
communication between the diverticular sac and the
74
Fig. 2: Endoscopic finding of a pharyngoesophageal
diverticulum.
esophageal lumen for fluent drainage of food material
without retention inside the diverticulum3,4. The main
concern with endoscopic treatment will be the risk of
recurrent laryngeal nerve injury as the K-J space lies in close
proximity to the entry point of the nerve into the larynx5.
Diverticulopexy was selected over diverticulectomy in the
present case because it was technically difficult to apply
stapling device across the entire neck of the diverticulum as
its lower edge was extending into thoracic inlet and the
surgery proves to be equally effective. However, a larger
number of cases and longer follow-up duration are needed to
make a definitive conclusion.
CONCLUSION
Diverticulopexy is a feasible and effective option for the
treatment of symptomatic K-J diverticulum.
ACKNOWLEDGEMENT
We wish to thank the Director General of Health, Malaysia for
permission to publish this paper.
REFERENCES
1. Ekberg O, Nylander G. Lateral diverticula from the pharyngo-esophageal
junction area. Radiology 1983; 146: 11722.
2. Rubesin SE, Levine MS. Killian-Jamieson diverticula: radiographic findings
in 16 patients. Am J Roentgenol 2001; 177: 8589.
3. Tang SJ, Tang L, Chen E, Myers LL. Flexible endoscopic Killian-Jamieson
diverticulotomy and literature review (with video). Gastrointest Endosc
2008; 68: 79093.
4. Mulder CJ, Costamagna G, Sakai P. Zenker's diverticulum: treatment using
a flexible endoscope. Endoscopy 2001; 33: 99197.
5. Rodgers PJ, Armstrong WB, Dana E. Killian-Jamieson diverticulum: a case
report and a review of the literature. Ann Otol Rhtnol Laryngol 2000; 109:
1087-91.
Med J Malaysia Vol 66 No 1 March 2011